69. Epilepsy – diagnosis, differential diagnosis and treatment.

Epilepsy. Diagnosis. Treatment.

• Epilepsies are defined as chronic diseases of the brain with various etiologies, which are characterized by repeating epileptic seizures, caused by extreme excitation of damaged neurons.
• A single seizure or a seizure during acute impairment without repetition does NOT mean a diagnosis of epilepsy.

Diagnosis

• The diagnosis is set when there are at least 2 unprovoked epileptic seizures.
• 4 stages of epilepsy diagnosis:

1. Seizure determination:
2. a. Differentiation from non-epileptic paroxysmal states as: syncope, migraine, TIA, movement disorders, sleep disorders, panic attacks, etc.
3. b. Differentiation from seizures in the course of metabolic dysbalance, cranial trauma, stroke, drug intoxication, sudden AED (antiepileptic drug) termination, alcohol intoxication or abstinence, etc., febrile seizures in childhood.
4. Epileptic seizure type determination according to the International classification of epileptic seizures.
5. Epileptic syndrome classification according to the International classification of epileptic syndromes.
6. Etiology verification.

Diagnostic Methods

• Detailed and precise disease history
• Clinical investigation – physical, neurological, mental abnormalities.
• ЕЕG and periodic ЕЕG control according to the therapeutic effect.
• Normal ЕЕG does NOT exclude the diagnosis epilepsy.
• EEG epileptiform activity without epileptic seizures does NOT mean epilepsy.
• The lack of EEG epileptiform activity in the course of treatment means that the treatment is probably effective.
• Video EEG, holter EEG, qEEG, EEG mapping, polysomnography – for a more precise Dg.
• Neuroimaging
• CT scan (contrast) – mainly in emergency for large structural lesions.
• МRI – an obligatory, safe and useful method for early Dg of refractory epilepsy and prognosis.
• fMRI – visualizes the anatomy of cognitive tasks by contrasting the oxygen blood level and predicts the effect of surgical treatment.
• MRS – for epileptogenic focus localization by visualization of biochemical processes modifications in the brain.
• SPECT or PET in cases with negative МRI – in the course of presurgical assessment.
• Magnitoencephalography (МЕG) – functional neuroimaging method for a registration of extracranial magnetic fields, generated by the brain electrical activity.
• Cerebral angiography – in the course of surgical treatment preparation.

Treatment

General principles

• Purpose of the treatment – seizure management, coping with psychic problems, resocialization and QOL improvement.
• The treatment is initiated in cases with a certain Dg epilepsy. In cases with a single epileptic seizure treatment is initiated when this is undoubted epilepsy start (typical EEG findings, brain damage) or when there significant risk for the patient in case of another seizure).